OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence

ICR 200802-0920-003 · OMB 0920-0789 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form No number Employee Survey Form and Instruction New Available
Form No number Manager Survey Form and Instruction New Repair queued
Supporting Statement Part B.doc Supporting Statement B Uploaded 2008-01-23 Available
Appendix D_IPV Workplace.1.21.08.doc Supplementary Document Uploaded 2008-01-23 Available
Appendix J _Workplace OMB Package_1.21.08.pdf Supplementary Document Uploaded 2008-01-23 Available
Appendix L_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document Uploaded 2007-11-02 Available
Appendix K_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document Uploaded 2007-11-02 Available
Appendix I_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document Uploaded 2007-11-02 Available
Appendix H_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document Uploaded 2007-11-02 Available
Appendix G_IPV Workplace OMB Package 10 18 07.doc Supplementary Document Uploaded 2007-11-02 Available
Appendix F_IPV Workplace OMB Package 10 21 07..pdf Supplementary Document Uploaded 2007-11-02 Repair queued
Appendix B_IPV Workplance OMB Package 10 22 07.doc Supplementary Document Uploaded 2007-11-02 Repair queued
Appendix E_ IPV Workplace OMB Package 10 21 07.doc Supplementary Document Uploaded 2007-11-02 Repair queued
Supporting Statement Part A.doc Supporting Statement A Uploaded 2008-01-29 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
183664 Employee Survey Form and Instruction New
183663 Manager Survey Form and Instruction New
ICR Details
0920-0789 200802-0920-003
Historical Active
HHS/CDC
Program Effectiveness Evaluation of a Workplace Intervention for Intimate Partner Violence
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 08/25/2008
Retrieve Notice of Action (NOA) 02/01/2008
Approved consistent with CDC response to OMB with the following terms of clearance: the survey will not be used to generate representative estimates, CDC is reminded to seek OMB approval prior to data collection, OMB does not approve the proposed lottery incentive.
  Inventory as of this Action Requested Previously Approved
12/31/2009 13 Months From Approved
3,000 0 0
1,125 0 0
0 0 0
Intimate partner violence (IPV) affects a substantial number of Americans, and there has recently been increasing recognition of the impact it has on the workplace. The purpose of the proposed evaluation is to document in detail the workplace IPV prevention activities delivered by the company, to determine the impact of these activities on short-term and long-term outcomes, and to determine the cost-effectiveness of the program.
US Code: 42 USC 301 Name of Law: Public Health Service Act
  
None
Not associated with rulemaking
  72 FR 10219 03/07/2007
72 FR 63610 11/09/2007
Yes
2
IC Title Form No. Form Name
Manager Survey No number Manager Survey
Employee Survey No number No name
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 3,000 0 0 3,000 0 0
Annual Time Burden (Hours) 1,125 0 0 1,125 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new data collection.
$293,820
Yes Part B of Supporting Statement
No
Uncollected
Uncollected
Uncollected
Uncollected
Maryam Daneshvar 4046394604
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/01/2008